1/97: How to Prevent Denials of Treatment! The Guardians of Truth: You, your doctor or your HMO?

American Medical Consumers, a for profit California Company established in 1992, focuses on empowering the patient as the central decision-maker of their medical care, with the responsibility to gather and maintain their own personal medical information. Much like Dr. Bernie Siegel's hope that his passive cancer patients will become respants (responsible participants in their medical care), AMC's approach is to encourage the patient to take control of the the medical records process.

In a recent interview with the IC Network, Dr. Riccardi offered "The patient.. the medical consumer.. is their own guardian of truth. Unfortunately, the moment when a patient is the most vulnerable and tired is when they must take action."

If you worry about being denied a treatment by a doctor or your HMO, you need to understand the difference between a "Medical Decision" and a "Benefits Decision." A "medical decision" is a specific recommendation made by your physician which focuses on treatment(s) that is medically recommended for your care. On the otherhand, a "Benefits Decision" focuses on cost and what the HMO will pay for. Dr. Riccardi states, "It's not always the HMO as the bad guy." Often, physicians do not make clear medical recommendations to the HMO. If you asked your doctor about Elmiron and s/he responded "It's not one of our approved medications," your physician has improperly substituted a benefit decision for a medical decision.

As the key decision maker for your medical care, your task is to keep your physician focused on providing you a medical recommendation by asking questions such as: 'Doctor, in your best medical judgement, what should be done here? What should we do?'" Remember, you have the advantage. The informed consent principle gives you the tools and method to the gather the specific medical information you need most from your doctor before you agree to any treatment, such as: (a) treatment benefits, (b) treatment risks, and (c) treatment alternatives.

Dr. Riccardi believes that many denial of services also relate to vague and inaccurate medical records maintained by the medical office team. He encourages you to maintain your own medical files as well as to verify the information maintained in your physicians records.

Keep consistent and clear records of all of your office visits. For each visit, keep a record of the following points:

1. Who is the physician present? What is their specialty, if any?
2. Why are you there?
3. What symptoms are you presenting?
4. What treatments are discussed? (Did you take notes?)
5. What are their pro's and con's.
6. Have you both agreed on what your next step will be?

For every medical appointment, have your doctor commit to writing the above points. If there is resistance to putting this in writing, explain that you have to make an "informed decision" and would like to talk with your spouse or family. If s/he refuses, summarize the points in a letter addressed to your physician. Ask that it be made part of your medical file. Ask that s/he respond within five days if there is any medical inaccuracies in your letter and recollection of your appointment.

What should you do if your HMO refuses treatment? Some patients choose to file a grievance with their HMO. This can, however, be counter productive. Dr. Riccardi states "A grievance will take the issue out of your doctors hands and make it one of utilization/benefits review." Your goal is to focus the institution on the medical decision and how your proper care can be addressed. Encourage your doctor to be specific with the HMO and that the desired treatment is medically necessary. If your doctor refuses, have s/he explain in writing why they aren't pursuing their medical recommendations? This information is central to any further any actions you may take.

The future of HMO's and managed care is clearly uncertain. As many companies struggle with the costs of services, patients can be left behind, particularly those with chronic or difficult illnesses. As is the key to living life more effectively with IC, the key to success of working with your physician and HMO is to be actively involved. Take responsibility for your medical records and be consistent about it. At a minimum, keep track of the physicians that you see and what you have discussed. With a solid foundation of information and records behind you and under you, you will have a much better chance of successfully resolving any treatment denials you may face.

More information on AMC services and fees can be obtained by e-mail: riccardi@medcomsumer.com. In the near future, they will have a world wide website located at: http://www.medconsumer.com.

~~~~~~~ ©1997 - The IC Network
This may be reproduced with permission of the IC Network. Just ask! I haven't turned anyone down yet!